Universal Health Coverage and the post-2015 development goal agenda. And Mrs Gauri

In a recent blogpost I asked whether Universal Health Coverage (UHC) is old wine in a new bottle, and if so whether that’s so bad.

I argued that UHC is ultimately about making sure that “everyone – whether rich or poor – gets the care they need without suffering undue financial hardship as a result.” I suggested UHC embraces three important concepts:

• equity: linking care to need, not to ability pay;• financial protection: making sure that people's use of needed care doesn't leave their family in poverty; and • quality of care: making sure providers make the right diagnosis, and prescribe a treatment that's appropriate and affordable.

These concepts aren’t new, and they don’t jump out at you from the name "UHC". But as an overarching label “UHC” isn’t bad. So, yes, old wine in a new bottle. But as I said, if by slapping a new label on the bottle, we get people more interested in the wine – even if the label is a bit misleading – that's ok, given the wine’s a good one.

Which brings me to a question that's on a lot of people’s lips right now: Could UHC be the right health goal for the post-2015 development goal agenda?

Can we “sell” UHC to Varun Gauri’s mom?

My colleague Varun Gauri wrote a nice paper recently – and a blogpost to accompany it – called “MDGs that Nudge”. His idea is that if international goals have any impact, they do so by inspiring people. For people to find them inspiring, goals should be framed in a way they’re “psychologically, morally, and politically salient”. This sounds quite complicated, but it’s not. What Varun is saying is that they should resonate with people. They should be goals people feel are important to pursue. And they should be expressed in a way people can relate to.

For people like me who struggle with words like “salient”, Varun has a simple rule of thumb: “If you can’t sell a goal to my mom, don’t bother with it.”

Everyone should receive the health services they need!

UHC essentially has two dimensions. The first is the idea that everyone – rich and poor alike – should get the health services they need. We could put this into a nice slogan that ought to rally Varun’s mom and her friends very nicely: Everyone should receive the health services they need!

I don’t know Mrs Gauri, but I think she’d probably agree this is morally salient. Allocating health services according to medical needs is an idea that people find intuitively fair – seeing a rich person get the care they need while a poor person goes without offends our basic sense of fairness.

Knowing Varun, I suspect his mom is pretty smart. She’ll want to know how we're going to operationalize this idea. This is where we have to ask Mrs Gauri to bear with us a bit.

We obviously can’t see whether everyone in a given country receives all the health services they need in a given year. We will need to work with samples – just some people, and just some health needs.

The people we sample should be a nationally representative sample. We can’t randomly sample health needs, but we can try to come up with some ‘tracers’ we all agree on. We should make sure they span all types of health service – prevention, treatment, rehabilitation, and palliative care. After all, people have needs for all these types of care. And we should make sure our tracers span all stages of the lifecycle – the prenatal period, infancy and early childhood, later childhood, adolescence, and the various phases of adulthood. The MDGs focused very firmly on some phases of the lifecycle. In the process, they probably lost some appeal. The next health development goals should probably be more inclusive.

So much for the principles – how do we proceed in practice? We actually already have some tracers and data for them, not just for populations as a whole but also for subpopulations such as the poorest 40%. We have data on childhood immunization: we know, for example, what fraction of young children are fully immunized in many countries, and what the fraction is among the poorest 40%. We have data for many countries on whether women aged 40-69 have received a mammogram. There are lots more indicators for preventive services that we have data for, and there are probably lots more we could get through surveys and make sense of if we continue to collect more and more biomarker data in household surveys.

Getting data on medical treatment will be harder. We want to know – for different types of health needs – whether a person sought treatment, whether they were correctly diagnosed by the provider they visited, and whether the provider gave them the correct treatment. A household survey won’t be much help on any of these. We need to see what happens during the consultation – if the consultation happens. We might need to use fake or “standardized” patients along the lines I wrote about in my “Shocking facts about primary health care in India” blogpost.

It’s a time-consuming exercise but it’s easy to explain. We’re simply asking whether a patient with, say, unstable angina will get diagnosed correctly and come out of the clinic with the right treatment. And we want to see whether this happens to the poorest 40% of people, not just those living in affluent neighborhoods in the capital city.

When we have our tracer indicators, we can come up with targets. They could be set either in terms of levels or annual changes. In both cases, we want to set targets for specific subpopulations as well, such as the poorest 40% of the population. So, for example, we could say that we want to see a 2% increase every year in the fraction of women aged 40-69 who receive a mammogram; and among the poorest 40% we want to see this fraction grow at 4% a year. Or – and this is probably easier to get across: by 2030 all women aged 40-69 will be regularly receiving a mammogram. End impoverishment caused by health spending!

I’m worried Mrs Gauri might be thinking she just got a whole lot more information than she really wanted. So let’s quickly turn to the other aspect of UHC.

What we’re after here is that when people use health services, they don’t put their family at financial risk. I suspect most of us would agree that, at the very minimum, people ought to be able to get the health services they need without impoverishing their family. This also makes for a nice slogan that should appeal to Mrs Gauri and her friends: Payments for health services should never push a family into poverty! Or how about this one: End impoverishment associated with health spending!

I think Mrs Gauri would probably agree that this too is morally salient. People don't choose to fall ill. It's not much fun being ill, and being ill tends to limit one's ability to do things and enjoy life. The idea that people may fall into poverty by having to paying for something that will simply make them better offends our basic sense of fairness. We don't feel the same way when people fall into poverty when they run into problems with their mortgage becauase they've bought a home that's larger or more luxurious than they can afford. Or when they vacation more often or more expensively than they can afford. Health spending is mostly involuntary or non-discretionary – this sets it apart from most other items of household expenditure.

We can get at the impoverishment issue using household survey data. We can see how much households spend out-of-pocket on health care, and how much they spend on everything else – food, clothing, housing, etc. Money spent on health care is money that can’t be spent on these things. We're looking to count instances of when out-of-pocket payments make the difference between a family being above the poverty line and being below it.

And now, if you’ll excuse me, there's a lady coming towards my office who bears a strong family resemblance to Varun.

I must remember to concede when I talk to her that even if I can explain UHC in a way that resonates with her, it doesn’t clinch the argument – there could be other health goals that might also resonate with her. As it happens, I happen to think UHC will likely do quite well when compared to other contenders.

Comments

I'm 100% in favor of Universal Health Care. I think it's a very good idea. In India, when you need a heart surgery, they(hospitals) make you deposit 3 lakhs. How can some people do that? They don't. They just die. And the efficiency of doctors is another concern. Doctors are not afraid of anyone because no one watches them and they are not sued like they are here in the U.S. People fear hospitals in India; sometimes you come home in even worse condition than when you went in. Overall, I'm totally in favor of Universal Health Care. This would be a blessing if it could work in India.

Dear Mrs Gauri,
I’m so happy you stumbled on my blog post featuring you! Thank you for taking the time to write down your thoughts on universal health coverage. Your points illustrate very nicely the inequities that UHC – as a concept – tries to capture.
With best wishes,
Adam Wagstaff

In all the discussions on and definitions about UHC, I have seen reference to the notion of a basic and defined package of services and benefits to treat / provide to people of all income levels who need health care, but I have not seen any reference to primary prevention. We need to reach people (and prevent ilness) before it takes place in the first instance. Exclusively curative approaches to improving the health of a nation won't work. Until we embed public health approaches in universal coverage discussions and until the package of services is based on the burden of disease and the epidemiology of infectious diseases in a country, we will forever be playing catch-up.

Thanks for your comment.
I actually tried to make it clear that all services – including preventive care – need to be captured. As I wrote:
“We can’t randomly sample health needs, but we can try to come up with some ‘tracers’ we all agree on. We should make sure they span all types of health service – prevention, treatment, rehabilitation, and palliative care. After all, people have needs for all these types of care.”

An excellent post Mr. Wagstaff and a very compelling case to make UHC part of the post-2015 agenda. I especially like the three essential, salient you might say, concepts you outline - equity, financial protection and quality of care. It is interesting that Mrs. Gauri commented with an example about heart surgery from India, where, sadly, those three vary across regions, cities, and private and public sectors. In our work of building capacity at pediatric cardiac centers in India and other countries we have found that the discrepancies there are even more pronounced, as pediatric cardiac services typically are not high revenue generating and are often crowded out by adult services. Yet, the need for those has always existed (1 in 120 children will be born with a congenital heart defect) and there is no known prevention. The Indian government recently announced a screening program for congenital defects but they did not discuss what infrastructure there will be to meet the newly created demand for health service by this program. Very few comprehensive pediatric heart centers with capability for infant and newborn heart surgery exist in the government sector. The centers in the private sector are expensive and essentially out of reach for the average family. It is also important to recognize that the existing centers are all clustered in selected metros and in states with relatively better human development indices.
So to go back to your topic - UHC is a great goal but it will require a lot of investment - infrastructure, well trained human resources, a good screening and referral network and good preventive programs, where feasible. The question is - are all countries ready to finance this endeavor and where is the funding going to come from.

Thanks for your great comment. A couple of thoughts on the point you raise at the end.

First, it’s inevitable that with limited resources countries will likely have to expand gradually – as their economies grow – the list of health service needs they commit to satisfying. It’s a tough decision, of course, but a necessary one; even very rich countries don’t promise absolutely everything. I suspect a consensus will likely emerge on what populations might reasonably expect depending on their country’s GDP per capita.

I can't agree with you more about the hard choices, although from my experience of working in "the field", it's even harder to say to the parents "sorry, your daughter's heart surgery is not our country's health priority now". But in reality, that is how most countries have dealt with allocation of resources - by focusing on the most immediate needs. Not sure if those were deliberate or instinctive decisions. We actually did some research (unscientific) and came up with a few health, socioeconomic and demographic characteristics a country would need in order to support sustainable pediatric cardiac services and economic development combined with good health and education policies were at the top of the list.
As for your point about doing more with the existing health resources, I have read both of those posts and I don't agree as much. There is acute lack of variety of medical specialists around the world and your blog post about India's quality of care proves it - poor regulation and very little time to spend with patients (because there are not enough doctors) result in bad quality of health service.
Ultimately, it's a fine balance between quality and efficiency and the hard truth is that unless there are strong policies in place, many countries suffer from inefficient public sector and poorly regulated and poor quality private sector. And there will be no one size-fits-all approach, each country will have to figure out their own way to provide wider coverage for its citizens. As you quote Ms Manuelyan Atinc in your blog post, Better health should be what we’re all about.
I really enjoy your blog posts, thank you!

You are absolutely right Adam, as well as UHC embracing the concepts of effective health care coverage, equity and financial protection, one of its most attractive features is that it is easy to sell. I think Mrs Gauri’s excellent comment captures the popular support for UHC perfectly. I remember my mother telling me similar tales about the UK before political pressure resulted in the launch of the NHS.
People worldwide understand the simple idea that people should get the health services they need without suffering financial hardship. More to the point, whilst we debate the merits of different goals, people are specifically demanding UHC from the political leaders. Here are some recent press articles to demonstrate this:
New York: http://www.legislativegazette.com/Articles-Top-Stories-c-2013-03-11-82933.113122-Gottfried-Perkins-introduce-universal-health-care-bill.html
Indonesia: http://www.channelnewsasia.com/stories/southeastasia/view/1252666/1/.html
“Portland’s Raging Grannies” check out the video!: http://www.statesmanjournal.com/VideoNetwork/2142352274001/Portland-Raging-Grannies
India: http://www.thejakartaglobe.com/international/india-poised-to-supply-free-drugs-to-12-billion-people/555046
Much as I searched Google, I struggled to find people taking to the streets demanding “an increase in healthy life expectancy”
This isn’t to say that the health community should not seek an overarching health outcome goal as well. It’s just that in this political world, with many competing agendas, it would be smart for the health community to pick a goal that is popular with all people and politicians across the globe.
More here…. http://uhcforward.org/blog/2013/feb/11/uhc-should-be-included-post-2015-development-agenda-because-it-popular-worldwide

Thanks, Rob. Good points. I agree that there also needs to be an overarching health goal that will pick up the positive and negative contributions of the various sectors that have impacts on health. It is ultimately good health we’re after. Interesting links! For me Portland's raging grannies were the best. I liked the guy who brought one the grannies a wooden spoon half way through. Should I be worried they weren't singing in unison (let alone harmony), or focus on the fact they were singing from the same sheet? Thanks for sharing. A.

I think you are adopting a populist goal, with populist rhetoric to boot. The goal has to be health. Health is not needing any health care. All UHC does is pay for medical-pharma-sector that has disputable uncertain and even negative effect on health. This is a terrible waste! fix that waste and bad service... and then expand access for the far fewer ill because numbers of ill will fall due to PREVENTING disease by reducing the factors.
An apple a day keeps the doctor away. This beats UHC, especially when you consider the price of apples and the apparent impossibility of quality dissease care for affordable price. The medical-pharma sector is extortionist (sure ,any business would do same if given a chance)and are using you and UHC rhetoric to make more and more money.
Helmets, traffic lights, speed limits, car inspections etc ... Fewer injuries every day. Sanitation, garbage collection, fewer rats and pigs in cities .... Far less disease for children, adults, those still unborn, billions of people with better health - and less need for disease care. Sugary sodas. Animal disease like rabies. Etc etc.
Sorry, but it is francly surprising that multi-sector WorLd Bank does not push prevention in the very center of its program as the main focus, or as the only program because of the large effect on population-wide health conditions. Or do you have to make programs only to benefit the health care sector? It seems that way because there is only UHC money-raising for the health care sector
So please Focus on PREVENTION first, second and third, especially prevention of disease and disability through non-health sector actions. Alcohol, tobacco, diet, sugar, salt, environment, pollution, infectious disease, etc.
Prevention cost a miniscule fraction of what it will cost the poor countries if UHC is done insted. You cannot do both on the margin, so choose the right thing - health - over populist UHC goal. World Bank advice should not "kill the patient". Thank you.

At some point the World Bank seems to have adopted the model of a charity. I do not see now UHC is about development. More health , especially for the poor, is about development. But UHC is populism, sorry.
There are far better ways to better population health for the poorest and the poor than payng taxpayer money to dysfunctional health centers staffed by overpaid workers with little skills and selling expired counterfiet medication. See please above the posthe lady who first answered, what the common view is of visiting doctors and hospitals. They may make you sicker, you may die. UHC makes sure that these service providers get paid. Service stays same. Patient may die, but they still get paid thanks to the taxpayer.
Money could be better spent on nonmedical prevention. Only 3% of prevention is in medical centers, rest is outside or the health sector!!! 97% of DALYs and medical expenses saved is ignored just so the the health care sector, which delivers only 3% of prevention and 100% of services for ill , this sector can grow and prosper and send envoys to WHO conferences in Geneva, to exchange populist speeches with envoys from other countries.
The same money that you propose to waste on UHC could buy more (or less , as relevant) of the sanitation, water, public health surveillance, car safety, breathable air, tobacco and alcohol reduction, infectious disease control, prostitution, condoms, breastfeeding, exercise, sugar, nontoxic food, sugary sodas, etc, etc. As long as any public health measure with a rate of return of 20% or more is undone, we should not give a single thought or a single cent to UHC in poor countries tha can ill afford the waste.
UHC is populism, not needed for better health status of poor people. And UHC will do nothing for the 1 billion chronically hungry.

It’s unfortunate that people are associating UHC with universal coverage of curative services and are assuming that primary care interventions are excluded. There is nothing in the definition of UHC to suggest this. UHC simply refers to people getting the health services they need. As Adam says this includes preventive services including immunisations, family planning services, health education messages, breastfeeding promotion, drug rehabilitation etc etc.
As the World Health Report 2010 shows, UHC is about all people getting all the health services they need without suffering financial hardship. It is a concept designed to incorporate all aspects of a health system and not to allow specific service sectors (eg expensive tertiary services) to dominate policy and resource allocations.
In fact many are seeing UHC as an opportunity to highlight the inefficient and inequitable allocation of scarce health resources and reverse this trend. See for example the Indian High Level Expert Group’s plan for UHC which argues that 70% of additional public financing should be allocated to PHC interventions. http://blogs.wsj.com/indiarealtime/2011/12/19/five-ways-to-improve-indian-health-care/?mod=google_news_blog

First, UHC is a policy goal, albeit an intermediate goal. (Ultimately we’re after better health (for everyone) and ensuring people have enough money left over after any health spending to buy other things they need and want.) Committing to the (intermediate) goal of UHC doesn’t say anything about the institutional arrangements to achieve this goal. In fact what’s really interesting is that countries are not using old health financing and delivery arrangements to pursue UHC for precisely the reasons you give. UHC is triggering a wholesale rethink about how health care is best financed and delivered. See my blog post on health reform in Asia from this time last year and the 22 UHC case studies that the World Bank recently published.

Second, as countries grow they can afford to commit to satisfying more and more health service needs. The “universal” bit of UHC is about who is covered, not what is covered. As countries grow, they’ll be able to cover more and more health needs; after some point, coverage may become comprehensive as well as universal. UHC doesn’t eliminate resource constraints and the need to limit what’s covered.

I see you have clearly captured the real meaning of UHC, and clarified the misconceptions.

UHC is really about ensuring access to the health care services people need. It is no rocket science.

I am however surprised that the UN High Level Panel did not list UHC as a goal despite overwhelming evidence and global consensus for the goal. This is very disappointing. Although the panel's report highlights the bold goal of ending poverty by 2030, ensuring gender equality, universal access to water and sanitation, I would really like to know why its goal 4 states only as: 'ensuring healthy lives'

I believe Mrs Gauri understands UHC, and she even supports it here. The same is likely the case for many women in sub-Saharan Africa who have limited or no access to essential health services they need. They want to get quality healthcare without deepening existing poverty levels.

UHC is more than just a goal; it is a system-oriented framework that guarantees that we can effectively knock out AIDS, malaria, TB and NCDs. It is simply inspiring.

We look forward to the report of the UN Open Working Group on sustainable development goals.

Please you have not mention this. I only find information about investment in One Health report from the World Bank two weeks ago.
. I am confused why Universal Health program and bureaucracy is wanted if World Bank makes good investment in One Health and saves many hundredof millions of lives this way in next 100 years. Climate change report from World Bank placed very high value on welfare of future generation. Do you do this, too, using how much for discount rates?
The US CDC website about pandemic says also reduce illness by several billion when contagion infect 40 % of all people in this One World. Can you explain , please, relation vis a vis Universal Health?